Pediatrician AND Ghostbuster

Last week in clinic I had possibly the strangest patient encounter ever.  I looked at my computer and it said, "7 year old with sinus pain".  I thought to myself, "This will be easy.  I'll take a look at her sinuses, maybe get a CT, maybe do antibiotics, and send her on her way."  

Not the case.  This little girl walks into my office with her parents, mom looking very concerned.  I start off by saying, "So, your daughter is here for sinus pain?"  Mom replies by saying, "No, that's not why she's here.  My daughter has been seeing ghosts."

Okay, stop.  Am I a pediatrician or a ghostbuster?

After I got over my initial shock, I began my interview.  I asked the patient to tell me about the ghosts.  She said they are black, white, all different colors; some look like people.  She sees them at home, school, everywhere.  I was a little worried to ask her if she saw them there in my office... I was afraid she'd say, "Yes, in fact there's one right next to you."  Then I asked her if the ghosts talk to her.  "No.  But they scratch me sometimes."  Mom piped in and said, "Yes, I've seen the scratches."  Then mom launched into a story about how she had gotten attacked by a ghost several years ago.  That's when I started to become skeptical.  Was this mom feeding into this child's "visions"?  Was mom psychologically in the state of mind to make medical decisions for this child?  I told her as respectfully as I could, "Ma'am, I'm sorry your daughter is seeing these frightening images, and I wish there were something I could do for you, but I'm really not trained to handle this.  I am here to rule out any MEDICAL causes for her hallucinations."  Oh, that did not go over well.  The little girl's mom started getting very heated up, exclaiming "I know my daughter is seeing ghosts.  There's nothing wrong with her medically.  She is seeing ghosts, like that little boy in The Sixth Sense.  I'm afraid they're going to start hurting her.  You have to do something to help us."  I don't know what she wanted me to do - perform an exorcism???  I calmly told her, "I'm very sorry she is so upset and scared.  I will try to find someone who is trained to help you."  That's when I called the psychiatrist.  He was very helpful and agreed to see my patient the very next week (usually not that fast).  Mom was okay with that, and after 20 minutes discussing ghosts, I said goodbye to this strange family.

It was definitely an interesting appointment, and worth writing about so I can laugh about it later.  But I do hope this girl finds some help.  She was sweet.  And who knows, maybe she IS seeing ghosts.  Yikes!!

Attitude adjustment

Lately I've been so negative.  If not out loud, then definitely in my thoughts.  I need to change my attitude.  Below are two ways I can think about my work week, negative vs. positive.

Negative:

I have been SO tired lately!  This rotation is kicking my butt.  We have to do all these stupid assignments and the cardiologists are making me drive all over the city to follow them around.  Monday I had to drive 3 HOURS each way to Ft. Hood and tomorrow I have to go to two hospitals to sit and listen to an EKG talk that I've already heard, ugh!  I have no energy, I'm tired of this rotation, and I'm tired of residency.  Maybe I shouldn't have been a doctor.

Positive:

Wow, I have really been working hard this rotation!  But I've been learning a LOT, and it will help me in the long run.  It's a tough rotation for sure, with all these tests and assignments.  But I've passed everything so far and it's a learning process, even if it is painful at times.  What a privilege that I get to work with these cardiologists, who are renowned in their field.  I get one-on-one teaching with them and I see some great cases by going to all these hospitals.  And even though I've heard the EKG talk before, I am certainly not an expert so I'm sure I'll learn something tomorrow.  Residency is tiring - I knew that going into it.  But I trust that this is where I'm meant to be, and God will give me rest and the strength I need to do this.

If only I could think positively all the time.  But it feels so unnatural and phony.  I suppose if I make a conscious effort to change my thoughts like that, then over time it will happen more and more naturally.  Well that's it for today.  Off to work!  :)

M.D. = Make Decisions

When I was a fourth year med student doing my Emergency Medicine rotation, one of the ER docs told me, "M.D. means Make Decisions."  I've always been pretty wishy-washy.  I have a hard time making decisions about the most trivial things.  Take my iPhone for example.  I spent about an hour in the AT&T store trying to decide if I wanted 8GB or 16GB, black or white (I ended up getting 16GB in black, in case you're wondering... after switching between white and black several times).  But now I'm a doctor and I'm supposed to make decisions everyday - sometimes tough or tricky decisions.  This is one of the key components of being a good doctor, and I've observed this in some of my favorite attendings.  The ability to make a decision and commit to it.

It doesn't come naturally to me (obviously, since I spend hours deciding on things like phone colors).  But every time a decision is placed in front of me as a doctor, I consciously remind myself, "Make a decision, Linda, and stick to it."

Yesterday I sent two kids to the PICU.  The first one was a 12 month old girl who had pneumonia and was working hard to breathe.  I did my assessment and decided I wasn't quite comfortable with her staying on the floor.  She's doing fine and her labs were reassuring... but she ended up on continuous nebs which is a reason to go to the PICU.  So maybe I made the right decision by chance.  Then in the middle of the night I got called for a 2 year old boy who was having difficulty breathing after being extubated (he was under general anesthesia for a small procedure).  When I got there he looked bad.  He was sucking his chest down to his spine and had a barking cough.  I told the Anesthesia guys, "Yes, he needs to go to the PICU" and together we came up with interventions for this little guy's upper airway problems.  He started looking a lot better and by the time he got to the PICU he looked 100% better.  I felt a little silly bringing a comfortable, crying baby to the PICU, but considering what he looked like when I first saw him, I felt very justified in my decision.  And I committed to it.  It was a good feeling.

I'm in a transition period now where I'm getting towards the end of my second year.  In July I will begin my third and final year of residency.  I will be expected to make decisions all the time.  I will be the senior resident on call and I'll have first and second year residents looking to me for answers.  It's a little scary, but I think I'm ready.  Or at least, I hope so.  We'll see!

Honduras

Wow, I am really bad at this blogging thing.  Good thing I don't have many readers, haha.  It's been over a month since I returned from Honduras.  I've been meaning to blog about it because it was such an amazing experience, but I just haven't gotten around to it until now.

We left on a Thursday at the end of January.  We flew into Tegucigalpa, the second most dangerous place for an airplane to land in the world (so I've heard... not sure what the first most dangerous place is).  The reason is because the runway is super short so the pilots have to time the landing just right.  Ours wasn't too bad at all.  I was surprised at how quickly we got there - it was a short 2 hour flight from Houston.  It was a beautiful sunny day when we landed.  We were greeted by some of the NCO's from JTF Bravo.  They drove us to the base where we met up with the rest of our team.  That night we packed up our supplies and learned how to perform maintenance checks on the HUMVEE's.  We went over the itinerary for the trip, and then rested up for the mission.

The next day we headed to Marcala, where we would conduct our 3-day household survey.  This is a project our residency program has been doing in conjunction with the Honduras Ministry of Health over the last several years.  We collect data on randomly selected children to assess for nutritional deficiencies and anemia.  Marcala is in the La Paz region of Honduras, near the El Salvador border.  It is a rural area where some of the poorest people of Honduras live.  We stayed in a local hotel called La Casona Inn.  The people who worked there were so friendly and down-to-earth, and they cooked the BEST food for us!  The first night there we organized all of our equipment in preparation for our surveys.  My friend Raman and I were assigned as the logistics officers so we spent HOURS going through all of the supplies and organizing them.  We were quite proud of our work.

We woke up EARLY for the surveys.  I woke up around 5:00 to inspect my HUMVEE.  Then we would eat breakfast around 6:00 (my favorite part was the plantains - yummy!!).  After that we'd gather our rucksacks and load them into the vehicles with plenty of water and MRE's.  The Honduran guards joined us around 7:00 and then we headed out!  We divided our group into five teams, Alpha through Echo (I was in team Echo).  Each team got an interpreter, one of the NCO's from JTF Bravo.  Ours was named Joanna, and she was very helpful and laid-back.  Driving to the houses was interesting.  The roads were ROUGH.  Some of them were just barely wide enough for our HUMVEE's, and most of them were rocky and unsteady.  Often we'd have a ditch on one side and a cliff on the other.  It was seriously dangerous!  In fact, I almost died one day (This is another story in itself, but basically I got my HUMVEE stuck in a piece of road that gave out under the tire; it could've flipped over and fallen off the cliff but fortunately the other tire remained on solid road.  We jumped out as soon as we got stuck, and another HUMVEE came and towed our vehicle out.  Craziness!!).  Sometimes we would drive up to 2 hours to get to our rally point.  From there we would hike an additional distance to the randomized households.  Some hikes were short (our first day the houses were literally down the street from the rally point), but some were painfully long.  Once we got to the house, our interpreter would greet the mother of the household, explain what we were doing, and start his/her questionnaire.  Meanwhile the medical personnel got ready to collect the data.  We weighed the kids, measured them using "Shore boards" and measured mid-arm circumferences.  Then we stuck them and gathered a drop of blood to check their hemoglobin level.  If they were anemic we gave them iron.  And we left every house with soap, toothbrushes, and dewormers.  A lot of the kids had round bellies that were probably filled with worms.

The best part about the household surveys was that we were outside.  It gets old being cooped up in the hospital all the time... It was nice to be able to enjoy the sunshine and the fresh air.  And the kids were so cute.  The second day of our surveys, my team met an incredibly nice family.  Not all of the people we surveyed were very receptive to what we were doing there.  But this family was so sweet and appreciative.  There were these two little boys who sat down next to me and started talking to me in Spanish (which unfortunately I don't understand since I took French in high school!).  I made do with body language and the 2 or 3 phrases of Spanish I know and we managed to communicate fairly well.  I showed them how to use my camera and they had a lot of fun with that.  The 2-year old boy we surveyed at that house was hilarious.  He was such a trooper.  He didn't even wince when we stuck him for his hemoglobin check - in fact, he laughed!  It was so funny.

The third day of our surveys was one of the most memorable ones, not necessarily in a good way!  This was the day of our infamous hike to San Francisco, a little town located way down in the valley.  We were told our HUMVEE's could not go past a certain point, so we ended up hiking all the way down into this valley - it took about 2 hours one way, and we were literally going down a 30-40 degree incline.  I thought my knees were going to give out, and when we stopped for a rest my thighs were shaking.  Of course since we were all a bunch of out-of-shape doctors, it was painful and everybody whined about it.  I have to say, though, the view was incredible.  And again, I was just happy to be outside.  The most frustrating part about that day was that when we got to where our household was supposed to be, nobody was home!  We tried to make the most of it and started handing out soap and dewormers to everyone we came across.  The hike back was exhausting.  Needless to say, I slept like a baby that night.

After our household surveys were done, we did a couple days of clinic.  The first day was for follow-ups from the previous mission.  There weren't very many patients that day.  The second day of clinic was our MEDRETE, an all-comers day that we announced to everyone in the local area.  We set up shop at a school, where we used their buildings for three stations - Preventive Medicine, Nutritional Surveys, and Clinic.  The residents worked the clinic.  I think there were over 300 patients there that day.  The clinic was pretty easy - mostly colds and rashes and stuff.  Nothing too crazy.  After our clinic day, we packed up our HUMVEE's and headed out for our hospital tour.  The first tour was at the regional La Paz hospital.  The second tour was at Hospital Escuela, one of the biggest hospitals in Honduras (located in Tegucigalpa).  We stayed at the Clarion hotel in Tegucigalpa our last two nights in Honduras - it was so nice!  Especially after "roughing" it for a week in Marcala and JTF Bravo.  One of our last nights there a bunch of us went out to a local bar.  It was so much fun!  There was a live band and they played all kinds of fun Latin music.  We all had a few drinks and danced it up in front of the stage (and ON the stage, haha).  The pictures from that night are hilarious.  Let's just say I have some good blackmail material for several of my co-workers...

I was sad to leave Honduras.  I loved being in a new country and doing something exciting and meaningful.  And it was nice to be away from the residency program for a little while.  I get tired of all the politics and demands of being a resident.  The trip came at the perfect time and I must say I came back feeling renewed and excited to be a doctor.  I wonder how long that will last... haha.

Now it's back to the grind!  More stories to come.  :)

Time to leave the country

That's right, I'm leaving the U.S.  I'm tired of residency.  I'm quitting.  I'm going to make a run for the border.

No, I'm actually going on a humanitarian medical mission trip.  It's a 10-day trip to Honduras with a group of military medical personnel and I leave this Thursday.  We'll be providing medical care to the local children there, as well as surveying for nutritional deficiencies and visiting regional hospitals.  I'm pretty excited.  I'll be sure to write about it when I get back.

It's actually perfect timing because I've been feeling restless.  It's been a month since my last blog entry and things have gone back to normal.  I've been doing research, which is interesting but can be a bit mundane.  I have my clinic once a week, which can also be pretty routine.  Not only routine, but it can be tiring and frustrating.  Yesterday I had a very disgruntled mom who was extremely rude to me.  I am usually quite patient and will put up with a lot from people.  But for some reason yesterday it really got to me.  I was in a bad mood the rest of the day.

Which is why I'm looking forward to going to a third world country where people have different perspectives.  People aren't so demanding and entitled.  At least, that's how it was in Kenya.  I'm guessing Honduras will be similar.  Whatever the case may be, I'm looking forward to a change in scenery.  A change in MY perspective.  Something to renew my love of medicine and children.  I've gotten somewhat disheartened over the last few weeks.  I've been feeling tired, inept, and unmotivated.  It's funny how residency works that way - it ebbs and flows.  There are times I love it and feel like I am right where I need to be.  Then there are other times I wonder why the heck I ever wanted to be a doctor.

So I guess it's time to make my escape.  Hasta luego!

My first code blue

A week ago I coded a patient for the first time.  (For non-medical people, a code blue or "coding" a patient means essentially that a patient is dying and needs resuscitation.)  And to make things worse, my patient was only 11 years old.

Stephen had come to the hospital in critical condition about 2 weeks prior to the code event.  He had gotten a very serious infection resulting in septic shock.  He was found unconscious and when he came to the hospital he had an oxygen saturation of 35% and a pH of 6.9 (both of these numbers are nearly incompatible with life).  He was resuscitated the first night there in the hospital and miraculously seemed to pull through the initial injury.  He was placed on a ventilator and received all kinds of drugs and blood products to keep him alive.  When I left for Christmas, he was still very ill but relatively stable.

I came back on December 28, a few days after his 11th birthday.  Not only did Stephen spend Christmas hooked up to life support in the Pediatric Intensive Care Unit (PICU), he also spent his birthday there.  When I returned I found him on higher vent settings than when I'd left (not a good sign) and also on dialysis because his kidneys were starting to fail.  At this point the prognosis was becoming more and more grim.  His parents knew, but were holding on to the hope that Stephen might surprise all of us.  He had been a premature baby who had several complications in the NICU and doctors had predicted that he probably wouldn't live very long - Stephen proved them wrong.  He was a rambunctious boy whose little sister adored him.  Although he had a few medical problems stemming from his history of prematurity, he was otherwise a typical boy.

The next morning, December 29, I arrived to the PICU at 6:00 am to start my shift.  Stephen was on even higher vent settings and my colleague reported to me that he had been unable to correct Stephen's acidosis.  His lungs were starting to fail and were unable to exchange carbon dioxide for oxygen, so he was accumulating large amounts of CO2, which gets converted to acid.  He was also not oxygenating his tissues, so his body was using anaerobic metabolism, which also results in acid.  This is very taxing on the body after awhile, especially the heart.  We had maxed out all of his vent settings, as well as his meds.  Around noon on that Monday, Stephen's time came.  I looked at the monitor and noticed his CO2 was now in the 150's (normal is 40), and his oxygen saturation was in the 50's (normal is 100%).  His lungs were failing and his heart was starting to tire out.  Sure enough, about an hour after his O2 sats had dropped his heart rate started to drop as well.  It happened quickly.  When that happens the monitor makes this awful sound - three loud beeps, over and over.  One of the NICU nurses once told me it sounds like it's saying "I am dead, I am dead."  I looked around and saw my own feelings reflected in everyone else's faces: fear, panic, apprehension about what to do.  Thankfully, my PICU attending was there and she immediately took charge.  She began to bark off orders and we all immediately returned to our senses - no time to process emotions, now we just had to act.  One of the nurses wheeled the code cart in, I grabbed the back board and placed it under Stephen's back.  One of the nurses began chest compressions.  Another nurse started opening up code meds and pushing epinephrine.  Still, the monitor kept beeping "I am dead, I am dead".  My attending ordered me to keep an eye on the monitor and read off the numbers, then told the nurse to stop compressions and check for a pulse.  No pulse.  She looked at me and told me I was up next for chest compressions.  I jumped up to the bed, thankful to have a role and to do something useful.  I began going through the motions, just like I'd been trained.  I tried not to pay attention to the sunken appearance of his chest and the bruises all over.

Then I heard a sound I don't think I'll forget for a long time.  Stephen's parents had rushed to the PICU as soon as they were informed he was being coded.  In the middle of my chest compressions I heard a loud, sobbing wail come from the nursing station.  I looked over and saw Stephen's mom clutching her chest, crying uncontrollably, falling to the floor in horror.  It was almost nauseating to witness her pain.  I felt a hard knot in the pit of my stomach, but had to keep doing what I was doing.  It was one of the hardest things I've done yet in residency.

The rest of the code was like a dream - or rather, a nightmare.  Everyone did their job and we managed to pull Stephen through... the first time.  His heart started beating again and we stopped compressions.  But we knew it wouldn't last long.  My attending talked to Stephen's parents and they agreed that if/when it happened again, we would try everything we could for ten minutes but if Stephen still wasn't doing well, we would let him go.  And just as predicted, Stephen began to crash again.  Around 1:30 pm it happened the same way - his oxygen saturation dropped, then his heart rate followed.  Once again we began chest compressions and started pushing meds.  This time it was even worse because Stephen's mother came right up next to him, holding his hand and crying "Please Stephen, please don't go!!  I love you so much!!  Please baby!"  I stood right next to her checking for a pulse in between compressions and I hated having to say in front of her, "No, still no pulse."  After ten minutes, we stopped compressions and I checked again.  No pulse.  I listened with my stethescope - no heartbeat.  The monitor was flatlined.  We stopped.  Stephen's mother wailed again.

The rest of the afternoon was very strange.  I felt like I wasn't really there.  Like I was outside of myself, watching myself go through the administrative tasks of calling the organ donor service and writing a death summary.  After the adrenaline had worn off, I felt extremely exhausted all of a sudden.  And numb.  I saw Stephen's parents walking around in shock and pain, and I felt numb.  I wondered what was wrong with me.  Had I become calloused?  Why wasn't I feeling anything?  I saw nurses crying, but I felt nothing.  Just shocked.

It was on my drive home that it hit me.  I was staring straight ahead, replaying the scene in my head.  I was imagining what it must've looked like for Stephen's mother to walk in and see me standing over her son's chest giving compressions and my attending yelling for code meds to be given.  Then I thought about what it would've been like if it were my little brother on that bed.  Stephen was only a few years younger than my brother Jacob.  I couldn't even bear the thought of seeing Jacob like that... swollen, bruised, eyes falling open, skin turning blue, getting compressions and hearing the monitor beeping "I am dead".  I lost it.  I started crying uncontrollably.  I cried and cried, all the way home.  I had a hard time sleeping that night.  Thankfully I wasn't alone.  My roommate kept me company.  But I got into my bed and cried myself to sleep.

The next few days were strange.  I thought I was okay but then all of a sudden I'd see the image of Stephen dying in my head and I'd be overcome with grief again.  I broke down crying to one of my mentors.  She was gracious and listened to me with deep empathy.  I cried myself to sleep again the second night after Stephen died.

I'm doing better now, but my heart still hurts for Stephen's family.  I pray that God is bringing them comfort and that Stephen is in a better place now.  You know, as difficult as this week was I am thankful that God gave me empathy for my patient.  I wanted to write about it so that I will not forget Stephen and what I learned from his death.  I know I will probably see more children die in my life - unfortunately it comes with the job that I've chosen.  But I don't want to ever forget the pain it causes the family.  I don't want to grow desensitized and lose my empathy.  True, it is something doctors have to deal with all the time so I will need to learn to cope with it and move on.  But for each patient's family, it isn't something that happens all the time.  It is a life-changing, heartbreaking event.  I hope that I can always remember that.

May Stephen rest in peace.

Reviving my blog

It's been a long time since I've written on this blog.  Part of the reason is because I don't have time (now that intern year is over I have a busy social life!) but also because I didn't think anyone really cared to hear my rambling.  However I think I may pick it up again because 1) it's therapeutic for me to write (so it doesn't really matter if anyone reads it), 2) it's a way to document stories from residency (so one day I can look back and laugh), and 3) somebody told me I should keep writing (probably my only reader!).  At any rate, I have a compelling and heartbreaking story to tell, which deserves its own post so I will start from there.